Dyan Islam Application Package91 MIAMI BEACH
NAME: Islam Dyan
Last Name
HOME ADDRESS: 1004 Biarritz Drive #3
Apt No. Home No./Street City State Zip Code
PHONE: 305-861-9911 dyanislam123@gmail.com
First Name
Miami Beach
CITY OF MIAMI BEACH
BOARD AND COMMITTEE APPLICATION FORM
Z
Florida
Middle Initial
33141
Home
Business Name:
Address:
Street
Work
Position:
City
Email Address
State Zip Code
Pursuant to City Code section 2-22(4) a and b: Members of agencies, boards, and committees shall be affiliated with the city; this
requirement shall be fulfilled in the following ways: a) an individual shall have been a resident of the city for a minimum of six
months; or b) an individual shall demonstrate ownership/interest for a minimum of six months in a business established in the city.
• Resident of Miami Beach for a minimum of six (6) months Yes
• Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six (6) months: No
• Are you a registered voter in Miami Beach: No
• (Please circle one): I am now a resident of: North Beach
• I am applying for an appointment because I have special abilities, knowledge and experience. Please list below:
• Are you presently a registered lobbyist with the City of Miami Beach? No
Please list your preferences in order of ranking [1] first choice [2] second choice, and [3] third choice. Please note that only tnree is1
choices will be observed by the City Clerk's Office. (Regular Boards of City)
Choice 1: Youth Commission
Choice 2:
Choice 3:
* Board members are required to file Form 1 — "Statement of Financial Interest" with the State.
If you seek appointment to a professional seat (e.g., lawyer, architect, etc.) on the Board of Adjustment, Design Review
Board, Historic Preservation Board or Planning Board, attach a copy of your currently -effectively license, and furnish the
following information:
Type of Professional License License Number
License Issuance Date
License Expiration Date
Note: If applying for Youth Advisory Board, please indicate your affiliation with the Scott Rakow Youth Center:
1. Past service on the Youth Center Advisory Board: No Years of Service:
2. Present participation in Youth Center activities by your children Yes if yes, please list the names of your children, their
ages, and which programs. List below:
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• Have you ever been convicted of a felony: No If yes, please explain in detail:
• Do you currently have a violation(s) of City of Miami Beach codes: No If yes, please explain in detail:
• Do you currently owe the City of Miami Beach any money: No
• Are you currently serving on any City Boards or Committees: No
• What organizations in the City of Miami Beach do you currently hold membership in?
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If yes, please explain in detail:
If yes, which board?
• I am now employed by the city of Miami Beach: No Which department?
• List all properties owned or have an interest in, which are located within the City of Miami Beach:
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The following information is voluntary and is neither part of your application nor has any bearing on your consideration for appointment. It is
being asked to comply with federal equal opportunity reporting requirements.
Race/Ethnic Categories
What is your race? Mark one or more races to indicate what you consider yourself to be. Asian or Pacific Islander
Other Description:
Are you Spanish/Hispanic/ Latino? Mark the "No" box if not Spanish / Hispanic / Latino. No
Physically Challenged: No
NOTE: If appointed, you will be required to follow certain laws which apply to city board/committee members.
These laws include, but are not limit , the following:
o Prohibition from directly or indirectly lobbying city personnel (Miami Beach City Code section 2-459).
o Prohibition from contracting with the city (Miami -Dade County Code section 2-11.1).
o Prohibition from lobbying before board/committee you have served on for period of one year after leaving office (Miami
Beach Code section 2-26).
o Requirement to disclose certain financial interests and gifts (Miami -Dade County Code section 2-11.1).
(re: CMB Community Development Advisory Committee): prohibition, during tenure and for one year after leaving office,
from having any interest in or receiving any benefit from Community Development Block Grant funds for either yourself,
or those with whom you have business or immediate family ties (CFR 570.611).
Upon request, copies of these laws may be obtained from the City Clerk.
"I hereby attest to the accuracy and truthfulness of the application and have received, read and will abide by Chapter 2, Article
VII — of the City Code "Standards of Conduct for City Officers, Employees and Agency Members."
I Dyan Islam agreed to the following terms on
Received in the City Clerk's Office by:
Name of Deputy Clerk Control No. Date
Full Name: Dyan Zilani Islam
D.O.B: November 30th 2005
School Name: Mater Beach Academy
Grade: 8th
Father's Full Name: Mohammed Rafiqul Islam
Permanent Address: 1004 Biarritz DR Apt3 Miami Beach FL- 33141
E-mail Address: dyanislam123(a)gmail.com
Contact Number: 786-236-9553
Hobby's: Love to play basketball, football, and soccer
Dyan Zilani Islam
Signature: DI
Date: 7/2/19
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